— 降低風險 · MEDIUM · MCQ —
護理師照護一位腹部手術後的病人，下列哪項評估發現是通知外科醫師的最高優先事項？
A nurse is caring for a client who is post-operative following an abdominal surgery. Which assessment finding is the highest priority to report to the surgeon?
- AAbsent bowel sounds in all four quadrants四個象限均無腸鳴音
- BRigid, board-like abdomen with guarding✓ 正解僵硬如木板般的腹部伴隨保護性肌緊張
- CSerosanguineous drainage on the surgical dressing手術敷料上有漿液血性滲出液
- DHeart rate of 95 beats per minute心率每分鐘 95 次
— Explanation · 中文詳解 —
腹部術後出現板狀腹（rigid, board-like abdomen）伴隨腹肌防禦（guarding）是腹膜炎的徵兆，代表可能發生吻合處滲漏或內出血，需立即評估並通知醫師處理，以免發展為敗血性休克。
A rigid, board-like abdomen with abdominal guarding after abdominal surgery is a sign of peritonitis and may indicate anastomotic leakage or internal bleeding; immediate assessment and notification of the physician are required to prevent progression to septic shock.
✦ 台美臨床差異
美國護理師常執行腹部聽診與觸診作為常規；台灣護理師執行頻率較低，多由醫師決定是否拆卸敷料檢查傷口。